key: cord-1034505-hqe8g6sl authors: Ali, K.; Raja, M. title: Evidence-based strategies to reduce contamination from aerosolised microbes in dental practice environment date: 2020-09-25 journal: Evid Based Dent DOI: 10.1038/s41432-020-0108-4 sha: 32881c392726298050bebdbe4eccaa19ff5b3619 doc_id: 1034505 cord_uid: hqe8g6sl Cohort selection The aim was to evaluate interventions to minimise microbial contamination from aerosol generating procedures in the dental office. Seven electronic databases were searched using key words such as 'aerosols', 'droplets', 'spatter', 'microbial loads' etc to identify relevant randomised controlled trials and prospective non-randomised clinical trials until 6 April 2020. Data sources PubMed; Scopus; Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews; Open Grey; ClinicalTrials.gov; National Research Register; and hand searches. Data analysis Eligible studies were analysed for effectiveness of various interventions on the microbial counts in the aerosols generated in the dental office using predefined criteria. Data were analysed for assessment of quality of evidence and confidence in the estimated effect, risk of bias and other analyses using Stata 15.1 software. PRISMA guidelines extension for network meta-analysis were followed for reporting. Results Initial search identified 266 studies, of which 35 were evaluated for full text. Finally, 29 studies fulfilled the eligibility criteria for qualitative synthesis. The majority of the included studies were published in the last decade, and 21 out of the 29 studies were randomised controlled trials. However, based on comparable procedural settings (study design, study populations, interventions and outcome measures), only 11 were eligible for contribution to the network meta-analysis. The setting of all interventions was ultrasonic scaling of adult patients in a clinical dental practice environment, and involved 16 direct and 29 indirect comparisons. A multivariate meta-analysis showed pre-procedural mouth rinse with tempered chlorhexidine 0.2% at 47°C was most effective in reducing post-procedural bacterial load compared to the control. A mean difference of -0.92 (95% CI -15.4 to -0.29) in log10 colony-forming units was observed in air samples within 90 cm of the dental unit. Conclusions Notwithstanding the limitations of this network meta-analysis, pre-procedural mouth rinse with tempered chlorhexidine appears to be most effective in reducing bacterial counts in aerosols generated during dental operative procedures. Further randomised controlled clinical trials based on robust designs are required to establish the effectiveness of antimicrobial agents in reducing aerosol-related microbial loads (bacteria and viruses) in clinical environments. Conclusions Notwithstanding the limitations of this network metaanalysis, pre-procedural mouth rinse with tempered chlorhexidine appears to be most effective in reducing bacterial counts in aerosols generated during dental operative procedures. COVID-19 pandemic has had the most remarkable impact on the provision of dental care in living memory. Coronavirus (SARS-CoV-2) is known to be present in nasopharyngeal secretions and saliva, and can spread through respiratory droplets and direct contact with inanimate objects. 3 Aerosol generating procedures (AGPs) in clinical dentistry remain a particular concern. AGPs can allow the virus to spread for considerable distances which may remain suspended in the air for several hours, rendering the environment a high-risk area for nosocomial spread. Evidence-based strategies to reduce contamination from aerosolised microbes in dental practice environment K. Ali 1 and M. Raja 2 • Use of pre-procedural mouth rinse with antimicrobial agents may help to mitigate the risks associated with aerosol generating procedures in dentistry, but further research is required to establish effectiveness of such measures. • Dental professionals should avoid aerosol generating procedures unless absolutely essential. Compliance with current guidelines on COVID-19 by relevant professional bodies remains essential as further good-quality evidence is gathered to reduce the risks of COVID-19 in clinical dental practice. The current meta-analysis focuses on the evidence underpinning interventions for minimising microbial contamination of aerosols in the dental office environment. While the use of pre-procedural antimicrobial mouth rinses to reduce microbial load in dental AGPs appears to be a promising option, a major limitation of evidence emanating from this review is that the included studies only evaluate the effects of interventions on aerosolised bacterial loads. Given that the most immediate and paramount concern at present relates to the spread of COVID-19 during dental AGPs, the findings appear to fall short of addressing this current challenge. CoV-2, consideration needs to be given to the growing incidence of allergy to chlorhexidine in the general population, including the risk of fatal anaphylaxis. 14 Antimicrobial agents including ICX (active ingredients: sodium percarbonate and silver nitrate) and povidone-iodine have demonstrable virucidal activity. 15, 16 Thus, addition of antimicrobial agents to dental unit water lines (DUWLs) offers another possible avenue for minimising microbial contamination of aerosols. Commissioning of future research to mitigate the effects of AGPs in dentistry will also need to account for costs, health and safety concerns, and research ethics. Notwithstanding the challenges of designing research projects, there is a clear case for investing in this area to address the dental healthcare needs of the population and to support the dental profession. World Health Organisation. Coronavirus disease (COVID-2019) Situation Reports Beware of the second wave of COVID-19 How it spreads Transmission routes of 2019-nCoV and controls in dental practice Dental policies and procedures Resources for COVID-19 Implications of COVID-19 for the safe management of general dental practice -a practical guide Aceves-Martins M, on behalf of the CoDER Working Group. Aerosol Generating Procedures and their Mitigation in International Dental Guidance Documents -A Rapid Review Guideline for testing chemical disinfectants regarding their virucidal activity within the field of human medicine: as of December 1st A novel coronavirus from patients with pneumonia in China Quantitative proteomic analysis of gingival crevicular fluid in different periodontal conditions Coronavirus COVID-19 impacts to dentistry and potential salivary diagnosis Chlorhexidine and hypersensitivity reactions in dentistry In Vitro Efficacy of Povidone-Iodine Nasal And Oral Antiseptic Preparations Against Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV-2). 2020. Preprint Topical preparations to reduce SARS-CoV-2 aerosolization in head and neck mucosal surgery